Intensive livestock operations, health, and quality of life among eastern North Carolina residents.

People who live near industrial swine operations have reported decreased health and quality of life. To investigate these issues, we surveyed residents of three rural communities, one in the vicinity of an approximately 6,000-head hog operation, one in the vicinity of two intensive cattle operations, and a third rural agricultural area without livestock operations that use liquid waste management systems. Trained interviewers obtained information about health symptoms and reduced quality of life during the previous 6 months. We completed 155 interviews, with a refusal rate of 14%. Community differences in the mean number of episodes were compared with adjustment for age, sex, smoking, and employment status. The average number of episodes of many symptoms was similar in the three communities; however, certain respiratory and gastrointestinal problems and mucous membrane irritation were elevated among residents in the vicinity of the hog operation. Residents in the vicinity of the hog operation reported increased occurrences of headaches, runny nose, sore throat, excessive coughing, diarrhea, and burning eyes as compared to residents of the community with no intensive livestock operations. Quality of life, as indicated by the number of times residents could not open their windows or go outside even in nice weather, was similar in the control and the community in the vicinity of the cattle operation but greatly reduced among residents near the hog operation. Respiratory and mucous membrane effects were consistent with the results of studies of occupational exposures among swine confinement-house workers and previous findings for neighbors of intensive swine operations. Long-term physical and mental health impacts could not be investigated in this study.

Industrial hog production has grown rapidly in North Carolina since the early 1980s. Once characterized by relatively small independently owned farms scattered across the state, hog production in North Carolina is now concentrated in the coastal plain region, under the domain of large corporate growers, and dominated by large-scale intensive operations (1,2). Persons who live near large hog operations have reported reduced quality of life as well as health problems related to airborne emissions from animal confinement houses, open waste lagoons, and spray fields (3)(4)(5)(6)(7)(8). Airborne emissions include hydrogen sulfide, ammonia, dusts, endotoxins, and complex mixtures of volatile organic compounds. Health effects from environmental exposures could occur through inflammatory, immunologic, irritant, neurochemical, and psychophysiologic mechanisms (5).
In contrast to the many studies of occupational exposures of swine confinement-house workers (9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25), only a few field studies have investigated the health effects of lower level environmental exposures. In a study of residents near hog facilities in North Carolina, Schiffman et al. (26) reported that persons exposed to odors from intensive hog operations experienced "more tension, more depression, more anger, more fatigue, and more confusion" than a group of unexposed persons. A study in Iowa (7) compared physical and mental health symptoms among people residing within a 2-mile radius of a 4,000-head swine operation and a control group in an area with no intensive livestock operation. Those who lived in the vicinity of the intensive hog operation reported higher frequencies of 14 of 18 physical health symptoms, especially respiratory symptoms. The Iowa study did not find an excess of mental health symptoms but, in contrast to the North Carolina study (26), it was not designed to evaluate symptoms at the time that odors were present.
The present study addressed a number of issues raised by previous research. Unlike studies of volunteers, the sample was drawn systematically from defined populations. To increase the levels of participation and prevent exclusions based on literacy or the ability to participate in a longer study, we did not ask participants to keep a diary or respond to questions at the times that airborne emissions from livestock operations were noticeable. Instead, we asked questions about the number of times that participants experienced the symptoms of interest during the previous 6 months. Because mood disturbance and mental health effects may be acute responses to the presence of odors, we focused on physical health and quality of life rather than on short-term mood changes. We achieved high levels of participation in the study by establishing cooperative relationships with local community based organizations in planning and conducting the research.
This study compared health symptoms in residents of three North Carolina communities, one in the vicinity of an intensive hog operation, one in the vicinity of two intensive cattle operations, and a third in a rural agricultural area where no livestock operations used liquid waste management systems. Although the primary motivation for the study came from an interest in airborne emissions from swine operations, the inclusion of people residing near cattle operations afforded an opportunity to examine possible health effects from a different kind of livestock, and also offered a second comparison community that may share other features common to communities with intensive livestock production.

Materials and Methods
Selection of communities. The North Carolina Division of Water Quality (Raleigh, NC) maintains a database on intensive livestock operations that use liquid waste management systems (27). Information on livestock operations included in the database as of January 1998 was merged with 1990 U.S. Census block group data (U.S. Census Bureau, Suitland, MD). Data for block groups, which average approximately 500 households, included information on population size, race, and poverty levels. Maps of the eastern part of North Carolina were prepared showing the locations of livestock operations, towns, roads, and churches. Community consultants experienced with the hog industry and the health concerns of community members met with university researchers to review the maps and choose potential study sites. Our goal was to choose three areas with similar economic and demographic characteristics where residents would be willing to participate in an interview and where existing community based organizations would be interested in working with researchers. We sought livestock areas with 80-100 households within a 2-mile radius of the livestock facility so that we would be able to obtain approximately 50 participants in each area.
The hog and cattle study areas were defined by a < 2-mile radius around the operations and each study area was contained within a single census block group. The hog operation was a feeder-to-finish facility with a head capacity of approximately 6,000, a steady-state live weight of approximately 800,000 pounds, and one lagoon. The cattle community contained two neighboring dairy operations with a combined head capacity of approximately 300, live weight of approximately 200,000 pounds, and two lagoons. The area with no intensive livestock operations extended across two block groups. Parts of two block groups were included to ensure that eligible households were at least 2 miles away from any livestock operation using a liquid waste management system. The median annual family income of the census block groups from which the study areas were chosen ranged from approximately $17,000-23,000 and the populations were between 65 and 90% African American.
All habitable dwellings in the study areas were enumerated. The location of each dwelling was noted on an enlarged area map and was assigned a unique study number. Information on street or road location and the type of dwelling was entered into a computerized database.
Questionnaire. A structured questionnaire was developed based on previous research findings and on discussions with community members who had experienced exposures from intensive livestock operations. In addition to symptoms identified by previous studies or community residents as possibly related to airborne emissions from livestock operations, we included symptoms that we did not believe would be related to airborne emissions to evaluate the possibility that residents of exposed communities might report excesses of all types of symptoms because of negative feelings about intensive livestock operations. The questionnaire was designed to obtain information about the frequency of occurrence of each symptom over the 6 months preceding the interview. Possible responses were never; rarely (once or twice over the past 6 months); sometimes (1-3 times per month); often (1 per week); and very often (twice a week or more over the past 6 months). After all of the structured questions had been asked, respondents were asked about aspects of the environment that may have affected their own health or the health of others in the household. Interviewers took notes to summarize the types of responses. At the end of the interview, participants were asked their age, occupation, household size, source of drinking water, and whether they or others in the household smoked tobacco. The interviewers recorded race, sex, and whether anyone other than the participant and interviewer were present during the interview.
Household interviews. Adults 18 years of age or older with no serious speech or mental impairment who lived in the current residence for 6 months or longer were eligible to respond to the questionnaire. The households of dairy operators who lived beside the cattle facility were excluded to avoid the complication of occupational exposures; the household of the swine facility operator was not within the 2-mile enumeration area of the facility. Interviews were conducted on Fridays and Saturdays in January and February 1999 by university-based staff. Interviewers were accompanied by a community consultant, a local resident recruited from the membership of the community based organization. The community consultant introduced the interviewer to the prospective respondent, explained the purpose and importance of the survey, and encouraged each person to participate. Interviewers were trained to administer the survey instrument systematically and uniformly to all respondents. The participant interview was conducted in a location of the participant's choosing. The questionnaire required less than 15 min to complete. The community consultant was not present for the interview unless the participant specifically asked the consultant to remain.
One adult from each household was invited to participate in the survey. Preference was given to the first person to answer the door if  the person was over 18 years old and lived in the household. Those who declined to participate because the time was inconvenient were offered alternative times and the visit was rescheduled. If no one was at home, the information was recorded on the tracking form. These households were visited a second time.
Households were visited sequentially using the enumeration map in approximate order of distance from the intensive livestock operation until a minimum sample size of 50 was reached. Informed consent was requested verbally by the trained interviewer. Statistial methods. Differences in symptoms among the three communities were evaluated by comparing the average number of episodes experienced over the last 6 months for each symptom. The number of episodes over the 6 months preceding the interview was scored according to the instructions given to respondents for responding to the frequency of symptoms. A response of "never" corresponded to 0 episodes. A response of "occasionally" corresponded to two episodes. "Sometimes" corresponded to 12 episodes (2/month), "often" corresponded to 26 episodes (1/week), and "very often" corresponded to 52 episodes (2/week). Adjusted mean differences in the numbers of episodes were calculated using linear regression to control for sex, age (19-44, 45-64, or 65-90 years), respondent's smoking status (yes or no), and employment outside the home (yes or no). These variables were considered potential confounders because they may be associated with exposure to airborne emissions and experience or reporting of symptoms. Because the five response categories for the number of episodes were highly skewed, regression models were also run with the dependent variable coded as the square root of the number of episodes and as 0-4.
The ratio of the P-coefficient (adjusted mean difference in number of episodes) to  Table 1 shows the numbers of households enumerated and surveyed. Enumerated households were within 2 miles of an intensive livestock operation in the cattle and hog communities. In the control area, enumerated households were > 2 miles from an intensive livestock operation in the control area. Approximately 100 households were enumerated in each area. Fifty interviews were completed in the cattle and control communities, and 55 interviews were completed in the hog community. The refusal rate was 23.1% in the control community, 10.7% in the cattle community, and 8.3% in the hog community.

Results
Characteristics of the respondents are shown in Table 2. The cattle community had the largest proportion of respondents older than 65 years of age. All three communities were predominantly African American. Approximately two-thirds of the participants were female. The proportion of respondents who reported smoking tobacco was lower in the hog community than in the other two communities, whereas the proportion employed outside of the home was higher. None of the study participants reported that they worked in the livestock industry. Household size was largest in the hog community.
Responses to the symptom questions in the three communities are shown in Table 3. The symptoms were categorized in six groups: upper respiratory and sinus, lower respiratory, gastrointestinal, skin and eye irritation, miscellaneous, and quality of life. For each community we tallied the number of persons who answered "sometimes," "often," or "very often" corresponding to . 12 episodes during the 6-month period. Table 3 also shows the percentage of "sometimes" or more often and the average number of episodes for the 6 months.
Most of the percentages in Table 3 are < 50; the majority of participants responded "never" or "occasionally" to most of the symptom questions. Among the upper respiratory and sinus conditions, the percentage of respondents reporting 2 12 episodes was the largest in the hog community except for plugged ears and scratchy throats. Percentages were generally intermediate in the cattle community. The percentage of respondents reporting . 12 episodes was generally smaller for lower respiratory, gastrointestinal, and skin or eye irritation symptoms. Percentages were the highest in the hog community for all four gastrointestinal symptoms. In all three communities, more than one-third of the participants reported experiencing joint or muscle pain and unexplained tiredness 2 12 times. By far the biggest differences between the communities were seen in the quality-of-life questions. Over half of the respondents in the hog community, as compared to less than one-fifth in the other two communities, reported not being able to open windows or go outside, even in nice weather, . 12 times over the last 6 months.  Table 4 shows the difference in the mean number of episodes adjusted for sex, age, smoking, and work outside the home; the SE of the I3coefficient; and the t-value, which is the ratio of the [-coefficient to its SE (see "Statistical Methods"). The adjusted mean differences for the cattle community were generally small, with lower mean scores (negative 3coefficients and t-values) for many symptoms in the cattle as compared to the control community. Only episodes of excessive coughing and heartburn occurred on average > 2 times more in the cattle than in the control community (P > 2), and the t-values for these differences were only approximately 1.0. All of the symptoms in the miscellaneous category appeared less frequently in the cattle than in the control community. Hearing problems showed the largest difference in adjusted mean episodes, although this is based on a small number of people in the higher categories (Table 3).
In contrast, there were many mean differences of more than two episodes for the hog as compared to the control community. The average number of episodes was the most consistently elevated for upper respiratory and sinus conditions, gastrointestinal conditions, and skin or eye irritation. t-Values for headache, runny nose, sore throat, excessive coughing, diarrhea, and burning eyes showed that residence in the hog community was an important predictor of these physical health symptoms. In  To evaluate the sensitivity of the regression results to the coding of the dependent variable, the models shown in Table 4 were rerun using values of the square root of the number of episodes and as 0, 1, 2, 3, and 4.
t-Values for differences between the hog community and the control community were larger in these models. The t-value for nausea/vomiting was 1.61 with the original metric, 2.68 using the square root of the number of episodes, and 2.88 with a coding of 0-4. To consider whether elevated gastrointestinal symptoms in the hog community might be related to well contamination, the models shown in Table 4  odor was noted as a problem for many residents of the hog community and for members ofthe residents' households.

Discussion
To our knowledge this is the first populationbased study of physical health symptoms and quality of life among community residents in North Carolina that focused on the possible health effects of airborne emissions from intensive livestock operations. The study sample was drawn from areas of the state with a majority ofAfrican American residents who have low median income. This was not unexpected because intensive hog operations in North Carolina are located disproportionately in poor and nonwhite areas (27). Despite the legacy of distrust of biomedical research in the African American community (28), refusal rates were low because of the participation of community based organizations in introducing researchers to participants. The preponderance of women in the study reflects, in part, who was at home and who answered the door when approached by the community consultant and interviewer.
A number of symptoms previously reported as elevated among persons occupationally exposed in swine confinement houses were elevated among the residents of the hog community as compared to the community with no livestock operations. In particular, headache, runny nose, sore throat, excessive coughing, diarrhea, and burning eyes were reported more frequently in the hog community. Members of the cattle community did not report similar elevations, nor did they report reduced quality of life. The quality of life measures (not opening of windows and not going outside even in nice weather) showed a large excess in the hog community.
As in all studies, measurement problems and differences between the communities other than the exposure of interest could have influenced the results. Recall bias is an issue in any survey. We were particularly concerned that residents living in proximity to a hog operation might report a greater number of symptoms because of negative  od that some respon-Levels of emissions and weather condiind that questions tions at the time interviewers were in the -eferred to problems field may also have influenced the findings. misunderstandings With one exception, interviewers did not nderestimate of the notice an odor from the hog operation while itions on health and conducting the interviews. If interviews had been conducted when odors were strong, 'sidents of the hog respondents may have reported a greater eported more symp-frequency of health symptoms. ings about the nega- The lack of environmental exposure operation on their monitoring data is also a concern in this f this had occurred, study. We assumed that if persons resided excess reports for within 2 miles of the hog operations, they the eight symptoms were exposed to the emissions. We were not gory, none of which able to distinguish higher or lower exposure ated to exposure to levels within the community. Exposure difrred with about the ferences could occur because of differences in )g and control com-distance, direction, elevation, physical barrisuggests that there ers, the amount of time spent at home, the ver-reporting among amount of time spent outdoors, and the availmmunity. Negative ability of air conditioning and filters in the been evident in the home. Quantitative evaluation of exposure hen respondents had differences between individuals would increase rt concerns beyond the ability of an epidemiologic study to ideni and quality-of-life tify health effects of airborne emissions. ;tructured question-Similarly, clinical or biologic measures of e 6, two persons in outcome would strengthen information xpressed concerns about relationships between environmental exposures to emissions from livestock operaof the survey may tions and health. Future studies could be iate of the impact of designed to obtain information on respiratoth of area residents. ry and immune function and standardized we studied an area clinical evaluation of physical and mental hog operation. We health conditions. Such studies could evalusee larger effects in ate possible mechanisms linking environmental exposures and health. NI and environmental injustice implications of this geographical pattern extend beyond the physiologic impact of airborne emissions to issues of well-water contamination (29) and the negative impact of noxious odors (8) on community economic development (30,31). Populations in these areas may be at greater risk of health impacts due to high disease rates (32,33), low income (27), and poor housing conditions. Future research could provide a better understanding of the health effects of intensive livestock operations by combining individual exposure assessment, physiologic measures, clinical evaluation of physical and mental health, and follow-up of exposed communities.